New Recommendations for Treatment of Schizophrenia

New Recommendations for Treatment of Schizophrenia

Newly published recommendations for pharmacological and psychosocial treatments from the Schizophrenia Patient Outcomes Research Team (PORT) are the first to address related treatments, such as smoking cessation, substance abuse, and weight loss, and they are the first update since 2003.1,2

The Schizophrenia PORT was created in 1992 with joint funding from the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) and the NIMH, as 1 of 14 task groups to address concerns about the appropriateness of care for common medical and psychiatric conditions.

This second update of the initial 1998 report3 was necessary, the PORT members explain, because “research on technologies for treatment of schizophrenia has continued to quickly evolve.” In addition to the publication of large clinical trials on the comparative effectiveness of first- and second-generation antipsychotic medications during this period (eg, CATIE,4 CUtLASS5), the PORT members point to substantial additions to the literature on neurocognitive impairments, co-occurring psychiatric and medical conditions, and recent-onset psychosis.

“It is imperative to update treatment recommendations to accommodate the ever-growing and shifting evidence base,” the PORT members declare.6

The current recommendations have been praised for their thoroughness and for their use of empirical data rather than opinion. However, the praise has been joined by observations that the gap between recommended treatments and the level of care accessible to those with schizophrenia remains as large today as when the initial PORT recommendations were first published.

In a commentary published with the PORT recommendations, Michael Hogan, PhD, New York State Office of Mental Health, considered progress over the decade since his comments accompanied the original PORT publication.7 First acknowledging the PORT research summaries and use of systematic evaluations as “impeccably done and a useful synthesis of knowledge,” Hogan then laments, “it is remarkable—and increasingly unacceptable—how little research has contributed to improvements in the general well-being of people with schizophrenia.”8

Harold Pincus, MD, department of psychiatry, Columbia University, noted “as important as this work is in providing guidance on evidence-based clinical practice, these reports do not ensure an impact on policy and practice.”9

Larry Davidson, PhD, department of psychiatry, Yale University, points to the inadequacy of even the most optimal of the currently available treatments. Davidson observes that the PORT psychosocial treatment recommendations are particularly important in the absence of a cure by medication or procedure.10

“It may be easier, or at least less difficult, for people to figure out how to live with schizophrenia,” Davidson argued, “than to be rid of it altogether.”

Lisa Dixon, MD, department of psychiatry, University of Maryland, and colleagues presented PORT psychosocial treatment recommendations. They considered the dilemma that the important but broad outcome of enhancing ability to live with schizophrenia is a difficult measure of the effectiveness of a psychosocial intervention.

In evaluating the evidence for cognitive remediation, for example, the researchers relate, “there was considerable debate about whether proximal outcomes, such as improvement on neuropsychological tests, should be considered a treatment benefit worthy of recommendation. While improvement on neuropsychological tests is the most proximal outcome to the intervention, the effect of such improvement on real-world functioning has yet to be consistently demonstrated.”2

Formulating PORT recommendations

PORT produced 8 psychosocial treatment recommendations, all as adjuncts to pharmacotherapy, in the areas of assertive community treatment, supported employment, cognitive behavioral therapy, family-based services, token economy, skills training, psychosocial interventions for alcohol and substance use disorders, and interventions for weight management. Other treatment areas deemed to have insufficient evidence to warrant recommendation were medication adherence, cognitive remediation, psychosocial treatments for recent-onset schizophrenia, and peer support and peer-delivered services.

This is the first time that PORT has reviewed treatments for alcohol or substance abuse and considered randomized clinical trials on both treatment delivery and the effectiveness of specific interventions. PORT recommends that persons with schizophrenia and comorbid alcohol or drug abuse should be offered substance abuse treatment. The key treatment elements should include “motivational enhancement and behavioral strategies that focus on engagement in treatment, coping skills training, relapse prevention training, and its delivery in a service model that is integrated with mental health care.”

An additional new psychosocial treatment recommendation is the management of weight gain—a health risk that has increased with use of some second-generation antipsychotics. PORT recommends that persons with schizophrenia who are either overweight (with a body mass index [BMI] of 25.0 to 29.9) or obese (BMI greater than 30.0) should be offered a psychosocial weight loss intervention of at least 3 months. PORT specifies that this intervention should involve nutritional counseling with emphasis on caloric expenditure and portion control, behavioral self-management, goal setting, regular weigh-ins, self-monitoring of daily food and activity levels, and dietary and physical activity modifications.

Of the 16 psychopharmacological treatment recommendations, 11 are revisions and 5 are new; another 3 earlier recommendations were deleted. An additional 13 treatment areas were reviewed, but these had insufficient evidence to warrant recommendations. The 5 new areas of recommendation were the combining of pharmacological with psychosocial approaches to smoking cessation, treatments in first-episode schizophrenia, monitoring clozapine levels, antipsychotic treatment of acute agitation, and repetitive transcranial magnetic stimulation for the short-term treatment of refractory auditory hallucinations.

Although the PORT members indicate there was good consensus in formulating the recommendations, one area of contention was whether there was sufficient evidence to recommend specific dosage ranges. The concerns were generally about the upper rather than lower dosage range, for which there are much less data, and a wide variance in practice. PORT did recommend ranges, but with the caveat that they serve only as guidelines for clinicians. They are not intended as proscriptions against the use of dosages outside the recommended range, but a reminder that there should be some rationale provided for the use of non-recommended dosages.

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Section Editor: Schizophrenia

Brian Miller, MD, PhD, MPH is Assistant Professor in the Department of Psychiatry and Health Behavior at Georgia Regents University. Current research focuses on inflammation/cytokines as a potential clinical state and relapse predictive marker in schizophrenia, and is funded by an NIMH K23 Mentored Patient-Oriented Research Career Development Award and the NIH Clinical Loan Repayment Program Award. He has been recognized with several young investigator awards, the 2010 Laughlin Fellowship from the American College of Psychiatrists, and a 2011 Exemplary Psychiatrist Award from the National Alliance on Mental Illness.